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Medicaid Winged Continued Stay Certification Request Form460 Braidwood Dr. Suite 300 Jackson, MS 39206Beneficiary InformationProvider InformationBeneficiary Name: Medicaid #:Physician Name: /Date
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How to fill out beneficiary information provider information
How to fill out beneficiary information provider information
01
To fill out beneficiary information, follow these steps:
02
Start by providing the full name of the beneficiary.
03
Enter the beneficiary's date of birth.
04
Next, provide the contact details of the beneficiary, including their phone number and email address.
05
Specify the relationship between the beneficiary and the provider.
06
If applicable, enter the beneficiary's address and any additional contact information.
07
To fill out provider information, follow these steps:
08
Begin by providing the full name of the provider.
09
Enter the provider's contact details, including their phone number and email address.
10
Specify the type of provider (e.g., healthcare provider, insurance provider, etc.).
11
If applicable, provide the provider's address and any additional contact information.
Who needs beneficiary information provider information?
01
Beneficiary information and provider information are required by individuals or organizations involved in insurance or healthcare processes.
02
This may include insurance companies, healthcare providers, medical facilities, government agencies, and individuals seeking to designate beneficiaries or receive services.
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